Provider First Line Business Practice Location Address:
808 W 58TH ST
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:
90037-3632
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-226-7443
Provider Business Practice Location Address Fax Number:
323-908-9617
Provider Enumeration Date:
03/31/2020