Provider First Line Business Practice Location Address:
712 IVY 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:
91204-1004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-247-0085
Provider Business Practice Location Address Fax Number:
818-247-9166
Provider Enumeration Date:
01/21/2007