Provider First Line Business Practice Location Address:
5740 LAKE MURRAY BLVD
Provider Second Line Business Practice Location Address:
OAKDALE HEIGHTS
Provider Business Practice Location Address City Name:
LA MESA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91942-2217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-461-9014
Provider Business Practice Location Address Fax Number:
619-461-7381
Provider Enumeration Date:
04/26/2007