Provider First Line Business Practice Location Address:
1319 ALLEN 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:
91201-1105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-648-7377
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/23/2013