Provider First Line Business Practice Location Address:
211 1/2 N AVENUE 50
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:
90042-3905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-419-9391
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/27/2022