Provider First Line Business Practice Location Address:
1424 ETHEL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91207-1240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-726-6876
Provider Business Practice Location Address Fax Number:
818-500-1123
Provider Enumeration Date:
04/09/2015