Provider First Line Business Practice Location Address:
7040 BROADWAY
Provider Second Line Business Practice Location Address:
A27
Provider Business Practice Location Address City Name:
LEMON GROVE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91945-1406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-667-1088
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/09/2009