Provider First Line Business Practice Location Address:
821 S SERRANO AVE APT 2
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:
90005-2744
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-791-6891
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/26/2026