Provider First Line Business Practice Location Address:
18856 ROSCOE BLVD
Provider Second Line Business Practice Location Address:
#B
Provider Business Practice Location Address City Name:
NORTHRIDGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91324-6300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-701-1058
Provider Business Practice Location Address Fax Number:
818-701-9037
Provider Enumeration Date:
09/15/2005