Provider First Line Business Practice Location Address:
1211 1ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN FERNANDO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91340-2802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-365-3182
Provider Business Practice Location Address Fax Number:
818-837-1143
Provider Enumeration Date:
09/20/2006