Provider First Line Business Practice Location Address:
1252 BROADWAY
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
EL CAJON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92021-4901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-440-0876
Provider Business Practice Location Address Fax Number:
619-440-9933
Provider Enumeration Date:
02/05/2007