Provider First Line Business Practice Location Address:
17402 CHATSWORTH STREET
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
GRANADA HILLS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91344
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-906-0406
Provider Business Practice Location Address Fax Number:
818-906-1566
Provider Enumeration Date:
12/27/2012