Provider First Line Business Practice Location Address:
458 W ELK 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:
91204-1586
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-550-1555
Provider Business Practice Location Address Fax Number:
818-396-5362
Provider Enumeration Date:
01/19/2012