Provider First Line Business Practice Location Address:
1013 E BROADWAY
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:
91205-1205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-662-8811
Provider Business Practice Location Address Fax Number:
818-662-8818
Provider Enumeration Date:
01/28/2008