Provider First Line Business Practice Location Address:
7732 SHOUP AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANOGA PARK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91304-2436
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-266-0779
Provider Business Practice Location Address Fax Number:
310-271-4010
Provider Enumeration Date:
05/21/2026