Provider First Line Business Practice Location Address:
19122 HALSTED ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTHRIDGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91324-1716
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
350-500-0005
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/03/2024