Provider First Line Business Practice Location Address:
17401 VINTAGE 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:
91325-1538
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-559-2836
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/19/2012