Provider First Line Business Practice Location Address:
508 N GENESEE AVE
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:
90036-1841
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-918-6158
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/27/2020