Provider First Line Business Practice Location Address:
12300 CANTARA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH HOLLYWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91605-1345
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
747-977-2437
Provider Business Practice Location Address Fax Number:
818-940-0340
Provider Enumeration Date:
06/08/2026