Provider First Line Business Practice Location Address: 
8330 RESEDA BLVD.
    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: 
91324
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
818-534-1820
    Provider Business Practice Location Address Fax Number: 
818-534-1821
    Provider Enumeration Date: 
08/04/2014