Provider First Line Business Practice Location Address:
1123 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:
91204-2212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-242-8804
Provider Business Practice Location Address Fax Number:
818-242-4442
Provider Enumeration Date:
10/05/2007