Provider First Line Business Practice Location Address:
542 N JUANITA AVE APT 8
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:
90004-2282
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-438-0112
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/12/2013