Provider First Line Business Practice Location Address:
6618 SAN FERNANDO RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91201-1703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-658-2122
Provider Business Practice Location Address Fax Number:
818-403-3386
Provider Enumeration Date:
03/11/2026