Provider First Line Business Practice Location Address:
11145 TAMPA AVE STE 15A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTHRIDGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91326-2265
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-468-7622
Provider Business Practice Location Address Fax Number:
818-428-1561
Provider Enumeration Date:
04/09/2012