Provider First Line Business Practice Location Address: 
5363 BALBOA BLVD
    Provider Second Line Business Practice Location Address: 
SUITE 436
    Provider Business Practice Location Address City Name: 
ENCINO
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
91316-2805
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
818-787-2838
    Provider Business Practice Location Address Fax Number: 
818-905-6610
    Provider Enumeration Date: 
11/20/2006