Provider First Line Business Practice Location Address:
16015 KINGSBURY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANADA HILLS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91344-7052
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-294-6762
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/18/2026