Provider First Line Business Practice Location Address: 
1777 VINE ST
    Provider Second Line Business Practice Location Address: 
404
    Provider Business Practice Location Address City Name: 
HOLLYWOOD
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
90028-5255
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
323-461-4676
    Provider Business Practice Location Address Fax Number: 
323-461-3664
    Provider Enumeration Date: 
08/30/2006