Provider First Line Business Practice Location Address:
3059 COUNTRY CLUB DR
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:
91208-1711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-434-3673
Provider Business Practice Location Address Fax Number:
818-548-1064
Provider Enumeration Date:
10/11/2005