Provider First Line Business Practice Location Address:
1000 BROADWAY AVE.
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
EL CAJON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92021-4803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-401-5500
Provider Business Practice Location Address Fax Number:
619-401-5454
Provider Enumeration Date:
03/12/2007