Provider First Line Business Practice Location Address:
1231 S PLYMOUTH BLVD APT 102
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:
90019-6881
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-290-2431
Provider Business Practice Location Address Fax Number:
562-264-1215
Provider Enumeration Date:
12/06/2019