Provider First Line Business Practice Location Address:
5565 GROSSMONT CENTER DR
Provider Second Line Business Practice Location Address:
BLDG 1, STE 227
Provider Business Practice Location Address City Name:
LA MESA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91942-3020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-464-1138
Provider Business Practice Location Address Fax Number:
619-464-4987
Provider Enumeration Date:
10/31/2006