Provider First Line Business Practice Location Address:
212 BAILEY ST APT 204
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:
90033-2460
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-923-7440
Provider Business Practice Location Address Fax Number:
954-923-1299
Provider Enumeration Date:
05/29/2019