Provider First Line Business Practice Location Address:
12230 SHADY HOLLOW LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTER RANCH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91326-3862
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-612-8511
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/21/2026