Provider First Line Business Practice Location Address:
1121 N FAIRFOX 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:
90046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-650-6363
Provider Business Practice Location Address Fax Number:
323-650-4377
Provider Enumeration Date:
05/22/2006