Provider First Line Business Practice Location Address:
5575 LAKE PARK WAY
Provider Second Line Business Practice Location Address:
SUITE 114
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-807-4300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/23/2012