Provider First Line Business Practice Location Address:
19646 BALLINGER 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:
91324-2103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-918-7223
Provider Business Practice Location Address Fax Number:
818-280-5673
Provider Enumeration Date:
04/15/2016