Provider First Line Business Practice Location Address:
9301 TAMPA AVE SPC 565
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:
91324-2503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-307-0719
Provider Business Practice Location Address Fax Number:
818-279-0658
Provider Enumeration Date:
01/30/2025