Provider First Line Business Practice Location Address:
1420 S CENTRAL AVE
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:
91204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-507-4139
Provider Business Practice Location Address Fax Number:
818-502-4754
Provider Enumeration Date:
10/24/2006