Provider First Line Business Practice Location Address:
554 S. SAN VICENTE BL.
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90048
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-653-6996
Provider Business Practice Location Address Fax Number:
928-962-4849
Provider Enumeration Date:
07/19/2006