Provider First Line Business Practice Location Address:
2122 W 107TH 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:
90047-4305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-696-9749
Provider Business Practice Location Address Fax Number:
323-696-9508
Provider Enumeration Date:
11/23/2016