Provider First Line Business Practice Location Address:
1026 S BROADWAY STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90015-4779
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-419-9555
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/31/2021