Provider First Line Business Practice Location Address:
8817 RESEDA BLVD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
NORTHRIDGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91324-4051
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-772-0176
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/05/2007