Provider First Line Business Practice Location Address:
1104 E COLORADO 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:
91205-1309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-500-8008
Provider Business Practice Location Address Fax Number:
818-500-8075
Provider Enumeration Date:
06/27/2005