Provider First Line Business Practice Location Address:
7138 SHOUP AVE
Provider Second Line Business Practice Location Address:
STE B4
Provider Business Practice Location Address City Name:
CANOGA PARK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91307-2383
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-887-1656
Provider Business Practice Location Address Fax Number:
818-887-1765
Provider Enumeration Date:
09/29/2005