Provider First Line Business Practice Location Address:
12739 VAN NUYS BOULEVARD
Provider Second Line Business Practice Location Address:
PACOIMA PLAZA S/C
Provider Business Practice Location Address City Name:
PACOIMA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91331-1627
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-890-1506
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/24/2006