Provider First Line Business Practice Location Address:
17852 MALDEN ST
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:
91325-3816
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-701-1800
Provider Business Practice Location Address Fax Number:
818-885-1171
Provider Enumeration Date:
03/31/2012