Provider First Line Business Practice Location Address:
1401 W KENNETH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91201-1421
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-241-7080
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/22/2007