Provider First Line Business Practice Location Address:
11145 TAMPA AVE
Provider Second Line Business Practice Location Address:
14A
Provider Business Practice Location Address City Name:
NORTHRIDGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91326-2255
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-366-0474
Provider Business Practice Location Address Fax Number:
818-474-7530
Provider Enumeration Date:
06/11/2009