Provider First Line Business Practice Location Address:
3223 BAGLEY AVE
Provider Second Line Business Practice Location Address:
SUITE NUMBER 209
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90034-2970
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-876-0128
Provider Business Practice Location Address Fax Number:
310-815-9770
Provider Enumeration Date:
08/19/2008