Provider First Line Business Practice Location Address:
1861 S ORANGE DR APT 4 1/2
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:
90019-5374
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-672-5588
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/30/2023