Provider First Line Business Practice Location Address:
1582 LA CORTA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEMON GROVE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91945-4319
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-578-8503
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/28/2026