Provider First Line Business Practice Location Address:
22024 LASSEN ST STE 115
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHATSWORTH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91311-8327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
424-495-4925
Provider Business Practice Location Address Fax Number:
424-495-4929
Provider Enumeration Date:
10/14/2025