Provider First Line Business Practice Location Address:
1505 1/2 12TH AVE
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:
90019-4319
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-895-9110
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/18/2018