Provider First Line Business Practice Location Address:
17724 HALSTED ST
Provider Second Line Business Practice Location Address:
UNIT B
Provider Business Practice Location Address City Name:
NORTHRIDGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91325-2025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-205-7223
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/29/2014