Provider First Line Business Practice Location Address:
1417 W KENNETH RD STE B
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:
91201-1487
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-532-4011
Provider Business Practice Location Address Fax Number:
818-960-0034
Provider Enumeration Date:
06/12/2013