Provider First Line Business Practice Location Address:
17730 LASSEN ST
Provider Second Line Business Practice Location Address:
APT. 201
Provider Business Practice Location Address City Name:
NORTHRIDGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91325-4700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-671-9880
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/02/2017