Provider First Line Business Practice Location Address:
456 W STOCKER ST STE C
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:
91202-3257
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-245-6466
Provider Business Practice Location Address Fax Number:
818-245-6467
Provider Enumeration Date:
04/28/2012