Provider First Line Business Practice Location Address:
9003 RESEDA BLVD
Provider Second Line Business Practice Location Address:
SUITE 208
Provider Business Practice Location Address City Name:
NORTHRIDGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91324-3920
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-878-1492
Provider Business Practice Location Address Fax Number:
818-772-2545
Provider Enumeration Date:
08/21/2006