Provider First Line Business Practice Location Address:
1139 N BRAND BLVD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91202-3000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-547-6929
Provider Business Practice Location Address Fax Number:
818-547-5853
Provider Enumeration Date:
12/26/2011