Provider First Line Business Practice Location Address:
1202 S CENTRAL 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:
91204-2504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-551-1323
Provider Business Practice Location Address Fax Number:
818-551-0074
Provider Enumeration Date:
05/12/2006