Provider First Line Business Practice Location Address:
18429 PRAIRIE ST APT 6
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTHRIDGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91325-2214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-429-5020
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/17/2021