Provider First Line Business Practice Location Address:
6744 BALBOA BLVD
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:
91406-5532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-988-7979
Provider Business Practice Location Address Fax Number:
818-787-7256
Provider Enumeration Date:
10/05/2005