Provider First Line Business Practice Location Address:
1213 THOMPSON AVE
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:
91201-1441
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-822-5332
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/17/2026