Provider First Line Business Practice Location Address:
200 PETER MORTON MEDICAL BLDG
Provider Second Line Business Practice Location Address:
365C
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90095-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-825-6836
Provider Business Practice Location Address Fax Number:
310-206-3607
Provider Enumeration Date:
02/24/2011