Provider First Line Business Practice Location Address:
5575 LAKE PARK WAY
Provider Second Line Business Practice Location Address:
STE. 114
Provider Business Practice Location Address City Name:
LA MESA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91942-1664
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-772-1164
Provider Business Practice Location Address Fax Number:
619-463-8986
Provider Enumeration Date:
07/12/2011