Provider First Line Business Practice Location Address:
22252 BASSETT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANOGA PARK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91303-2307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-590-1159
Provider Business Practice Location Address Fax Number:
818-347-9331
Provider Enumeration Date:
03/19/2021