Provider First Line Business Practice Location Address: 
732 MOTT ST
    Provider Second Line Business Practice Location Address: 
SUITE 100
    Provider Business Practice Location Address City Name: 
SAN FERNANDO
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
91340-4237
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
818-963-5690
    Provider Business Practice Location Address Fax Number: 
818-365-0726
    Provider Enumeration Date: 
11/06/2013