Provider First Line Business Practice Location Address:
1130 W 30TH ST
Provider Second Line Business Practice Location Address:
APT 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:
90007-5318
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-304-1917
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/22/2010