Provider First Line Business Practice Location Address:
1407 1/2 W KENNETH RD APT C
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:
91201-1421
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-493-7149
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/14/2026