Provider First Line Business Practice Location Address:
1540 ALCAZAR STREET
Provider Second Line Business Practice Location Address:
CHP 133
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90089
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-442-2149
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/25/2017