Provider First Line Business Practice Location Address:
19641 1/2 CANTARA ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RESEDA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91335
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-349-9960
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/07/2026