Provider First Line Business Practice Location Address:
17502 CHASE 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:
91325-3918
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-819-5471
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/06/2026