Provider First Line Business Practice Location Address:
4240 W 62ND 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:
90043-3615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-299-0369
Provider Business Practice Location Address Fax Number:
323-290-2226
Provider Enumeration Date:
12/16/2013