Provider First Line Business Practice Location Address:
1625 E 4TH 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:
90033-4201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-859-2823
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/26/2018