Provider First Line Business Practice Location Address:
240 S JACKSON 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:
91205-1395
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-241-9611
Provider Business Practice Location Address Fax Number:
818-302-1699
Provider Enumeration Date:
10/23/2006