Provider First Line Business Practice Location Address:
122 N EDGEMONT ST APT B
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:
90004-6234
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-633-5623
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/04/2026