Provider First Line Business Practice Location Address:
1840 N KENMORE AVE APT 306
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:
90027-4072
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-492-0439
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/15/2025