Provider First Line Business Practice Location Address:
5958 VINELAND AVE STE I
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH HOLLYWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91601-1329
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-579-4143
Provider Business Practice Location Address Fax Number:
818-579-4144
Provider Enumeration Date:
08/17/2018