Provider First Line Business Practice Location Address:
PO BOX 280028
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTHRIDGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91328-0028
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-882-0122
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/22/2026