Provider First Line Business Practice Location Address:
1149 ALLEN AVE
Provider Second Line Business Practice Location Address:
APT 7
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91201-3361
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-424-0009
Provider Business Practice Location Address Fax Number:
818-409-0181
Provider Enumeration Date:
10/29/2013