Provider First Line Business Practice Location Address:
1610 LAKE ST
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:
91201-2610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-343-1809
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/24/2026