Provider First Line Business Practice Location Address:
200 UCLA MEDICAL PLZ STE 365C
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:
90095-5133
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-206-7663
Provider Business Practice Location Address Fax Number:
650-498-6205
Provider Enumeration Date:
03/26/2019