Provider First Line Business Practice Location Address:
6568 5TH AVE
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:
90043-4511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-758-5433
Provider Business Practice Location Address Fax Number:
800-455-2142
Provider Enumeration Date:
11/30/2015