Provider First Line Business Practice Location Address:
12100 SHADOW RIDGE WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTER RANCH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91326-3827
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-807-5374
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/03/2026