Provider First Line Business Practice Location Address: 
12038 VENTURA BLVD STE A
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
STUDIO CITY
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
91604-2608
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
818-508-0800
    Provider Business Practice Location Address Fax Number: 
818-500-0012
    Provider Enumeration Date: 
12/01/2015