Provider First Line Business Practice Location Address:
3959 LAUREL CYN BL.
Provider Second Line Business Practice Location Address:
STE 'C'
Provider Business Practice Location Address City Name:
STUDIO CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91604-3711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-506-6663
Provider Business Practice Location Address Fax Number:
818-506-2505
Provider Enumeration Date:
09/13/2006