Provider First Line Business Practice Location Address:
16017 BASSET ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VAN NUYS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-735-5454
Provider Business Practice Location Address Fax Number:
323-735-5445
Provider Enumeration Date:
05/30/2008