Provider First Line Business Practice Location Address:
5480 BALTIMORE DR STE 201
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-259-4983
Provider Business Practice Location Address Fax Number:
888-978-2712
Provider Enumeration Date:
01/12/2012