Provider First Line Business Practice Location Address: 
16921 PARTHENIA ST
    Provider Second Line Business Practice Location Address: 
SUITE 302
    Provider Business Practice Location Address City Name: 
NORTHRIDGE
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
91343-4553
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
818-830-9889
    Provider Business Practice Location Address Fax Number: 
818-830-9898
    Provider Enumeration Date: 
03/19/2013