Provider First Line Business Practice Location Address: 
11225 TAMPA AVE
    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: 
91326-1610
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
805-279-7899
    Provider Business Practice Location Address Fax Number: 
805-583-3438
    Provider Enumeration Date: 
11/20/2015