Provider First Line Business Practice Location Address: 
17425 PARTHENIA ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
NORTHRIDGE
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
91325-3240
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
818-298-1442
    Provider Business Practice Location Address Fax Number: 
818-775-1176
    Provider Enumeration Date: 
07/28/2011