Provider First Line Business Practice Location Address: 
6350 LAUREL CANYON BLVD
    Provider Second Line Business Practice Location Address: 
370
    Provider Business Practice Location Address City Name: 
NORTH HOLLYWOOD
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
91606-3200
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
818-927-4404
    Provider Business Practice Location Address Fax Number: 
818-927-4405
    Provider Enumeration Date: 
11/17/2015