Provider First Line Business Practice Location Address:
3148 W 11TH ST
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:
90006-2322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-200-2591
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/20/2020