Provider First Line Business Practice Location Address:
116 EAST BROADWAY
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:
91205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-548-0999
Provider Business Practice Location Address Fax Number:
818-548-1555
Provider Enumeration Date:
04/30/2007