Provider First Line Business Practice Location Address:
1252 THOMPSON AVE
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:
91201-1442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-245-5362
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/10/2025