Provider First Line Business Practice Location Address:
1685 E MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
EL CAJON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92021-5225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-579-8681
Provider Business Practice Location Address Fax Number:
619-579-0678
Provider Enumeration Date:
05/25/2006