Provider First Line Business Practice Location Address:
1605 EASTLAKE 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:
90033-1009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-226-8847
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/24/2012