Provider First Line Business Practice Location Address:
1126 E 82ND ST
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:
90001-3310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-484-0039
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/21/2025