Provider First Line Business Practice Location Address:
17646 LASSEN ST
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
NORTHRIDGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91325-1452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-998-3818
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/20/2013