Provider First Line Business Practice Location Address:
5128 NEWCASTLE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ENCINO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91316-3511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-590-6443
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/28/2026