Provider First Line Business Practice Location Address:
632 W ELK AVE
Provider Second Line Business Practice Location Address:
UNIT #101
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91204-1404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-547-4904
Provider Business Practice Location Address Fax Number:
818-547-4905
Provider Enumeration Date:
02/01/2008