Provider First Line Business Practice Location Address: 
9221 CORBIN AVE
    Provider Second Line Business Practice Location Address: 
SUITE 150
    Provider Business Practice Location Address City Name: 
NORTHRIDGE
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
91324-2483
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
818-701-5438
    Provider Business Practice Location Address Fax Number: 
818-701-0249
    Provider Enumeration Date: 
03/10/2007