Provider First Line Business Practice Location Address:
17419 LASSEN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTHRIDGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91325-1515
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-455-2586
Provider Business Practice Location Address Fax Number:
661-480-5496
Provider Enumeration Date:
05/19/2023