Provider First Line Business Practice Location Address: 
6922 TOBIAS AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
VAN NUYS
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
91405-3933
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
323-422-1313
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/17/2014