Provider First Line Business Practice Location Address:
658 HAWTHORNE ST
Provider Second Line Business Practice Location Address:
UNIT B
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91204-1002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-230-2130
Provider Business Practice Location Address Fax Number:
818-660-2684
Provider Enumeration Date:
09/30/2009