Provider First Line Business Practice Location Address: 
5557 WEST 6TH STREET
    Provider Second Line Business Practice Location Address: 
APARTMENT # 1101
    Provider Business Practice Location Address City Name: 
LA
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
90036
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
303-653-6980
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/13/2007