Provider First Line Business Practice Location Address:
650 CHARLES YOUNG DR S
Provider Second Line Business Practice Location Address:
ROOM A2-125 CHS
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90095-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-825-8711
Provider Business Practice Location Address Fax Number:
310-206-3566
Provider Enumeration Date:
10/27/2014