Provider First Line Business Practice Location Address:
4711 4TH 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:
91941-5316
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-462-7890
Provider Business Practice Location Address Fax Number:
619-697-9389
Provider Enumeration Date:
05/21/2007