Provider First Line Business Practice Location Address:
1456 WESTERN AVE
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:
91201-1214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-240-0907
Provider Business Practice Location Address Fax Number:
818-247-4887
Provider Enumeration Date:
07/27/2006