Provider First Line Business Practice Location Address: 
1136 N FAIRFAX AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
WEST HOLLYWOOD
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
90046-5307
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
323-650-6936
    Provider Business Practice Location Address Fax Number: 
323-654-2593
    Provider Enumeration Date: 
02/07/2007