Provider First Line Business Practice Location Address: 
12400 W MAGNOLIA BLVD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
VALLEY VILLAGE
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
91607
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
818-495-4300
    Provider Business Practice Location Address Fax Number: 
818-495-4300
    Provider Enumeration Date: 
08/10/2016