Provider First Line Business Practice Location Address:
1804 W 4TH 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:
90057-3002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-699-6969
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/27/2023