Provider First Line Business Practice Location Address:
1707 1/2 4TH AVE
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:
90019-6134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-465-5998
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/06/2026