Provider First Line Business Practice Location Address:
4128 S BROADWAY
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:
90037-2221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-234-9956
Provider Business Practice Location Address Fax Number:
323-234-0060
Provider Enumeration Date:
08/03/2005