Provider First Line Business Practice Location Address:
1557 THE MIDWAY ST
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:
91208-2802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-500-1254
Provider Business Practice Location Address Fax Number:
818-500-1279
Provider Enumeration Date:
05/24/2007