Provider First Line Business Practice Location Address: 
421 ARDEN AVE
    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: 
91203-4008
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
818-268-9404
    Provider Business Practice Location Address Fax Number: 
818-450-0244
    Provider Enumeration Date: 
08/09/2018