Provider First Line Business Practice Location Address:
12756 VAN NUYS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PACOIMA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91331-1626
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-896-0531
Provider Business Practice Location Address Fax Number:
818-896-5850
Provider Enumeration Date:
08/29/2005