Provider First Line Business Practice Location Address:
826A S LOS ANGELES 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:
90014-3302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-748-7788
Provider Business Practice Location Address Fax Number:
310-629-5311
Provider Enumeration Date:
10/03/2023