Provider First Line Business Practice Location Address:
4215 SPRING STREET
Provider Second Line Business Practice Location Address:
#210
Provider Business Practice Location Address City Name:
LA MESA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91941-7346
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-589-8971
Provider Business Practice Location Address Fax Number:
619-463-9684
Provider Enumeration Date:
10/04/2006