Provider First Line Business Practice Location Address:
1412 GROVELAND TER
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL CAJON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92021-3418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-631-7000
Provider Business Practice Location Address Fax Number:
619-631-7591
Provider Enumeration Date:
11/20/2014