Provider First Line Business Practice Location Address:
1300 NORTH VERMONT AVENUE
Provider Second Line Business Practice Location Address:
SUITE 804
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-662-9711
Provider Business Practice Location Address Fax Number:
323-662-9731
Provider Enumeration Date:
11/30/2006