Provider First Line Business Practice Location Address:
605 WEST 113 TH. STREET
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:
90044
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
855-652-5259
Provider Business Practice Location Address Fax Number:
323-242-0487
Provider Enumeration Date:
09/01/2016