Provider First Line Business Practice Location Address:
12700 BLYTHE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH HOLLYWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91605-2123
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-667-1161
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/17/2025