Provider First Line Business Practice Location Address:
926 S MANHATTAN PL APT 201
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:
90019-2364
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-294-3272
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/11/2025