Provider First Line Business Practice Location Address:
17806 LASSEN ST
Provider Second Line Business Practice Location Address:
113
Provider Business Practice Location Address City Name:
NORTHRIDGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91325-4817
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-268-0556
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/12/2010