Provider First Line Business Practice Location Address:
1000 ORANGE GROVE AVE APT 5
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:
91205-1288
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-862-0923
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/14/2025