Provider First Line Business Practice Location Address:
108 E 47TH PL APT 1
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:
90011-3972
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-682-2840
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/03/2026