Provider First Line Business Practice Location Address:
9301 TAMPA AVE UNIT 169
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:
91324-2577
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-559-9458
Provider Business Practice Location Address Fax Number:
213-559-9476
Provider Enumeration Date:
01/29/2026