Provider First Line Business Practice Location Address:
8708 DALLAS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA MESA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91942-3201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-432-8010
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/15/2026