Provider First Line Business Practice Location Address:
11225 TAMPA AVE
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:
91326-1610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-279-7899
Provider Business Practice Location Address Fax Number:
805-583-3438
Provider Enumeration Date:
11/20/2015