Provider First Line Business Practice Location Address:
1234 GRANVILLE AVENUE
Provider Second Line Business Practice Location Address:
#1
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90025-1685
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-231-4391
Provider Business Practice Location Address Fax Number:
310-231-4390
Provider Enumeration Date:
11/30/2006