Provider First Line Business Practice Location Address:
8526 GRAPE ST
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:
90001-4134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-586-6469
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/18/2008