Provider First Line Business Practice Location Address:
815 S CENTRAL AVE
Provider Second Line Business Practice Location Address:
SUITE #26
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91204-2046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-247-7650
Provider Business Practice Location Address Fax Number:
818-247-7961
Provider Enumeration Date:
06/16/2005