Provider First Line Business Practice Location Address:
7155 BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEMON GROVE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91945-1408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-315-0192
Provider Business Practice Location Address Fax Number:
619-337-2857
Provider Enumeration Date:
05/18/2016