Provider First Line Business Practice Location Address:
5308 LAKE MURRAY BLVD STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA MESA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91942-1334
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-464-4411
Provider Business Practice Location Address Fax Number:
619-464-4411
Provider Enumeration Date:
10/13/2005