Provider First Line Business Practice Location Address:
5000 LANKERSHIM BLVD
Provider Second Line Business Practice Location Address:
STE 106
Provider Business Practice Location Address City Name:
NORTH HOLLYWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
747-389-8736
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/14/2025