Provider First Line Business Practice Location Address:
2728 W 54TH 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:
90043-2644
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-500-1141
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/15/2021