Provider First Line Business Practice Location Address:
1423 W 66TH 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:
90047-2011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-920-4856
Provider Business Practice Location Address Fax Number:
323-451-8098
Provider Enumeration Date:
04/22/2020