Provider First Line Business Practice Location Address:
8100 BROADWAY STE A
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:
91945-2667
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-697-9501
Provider Business Practice Location Address Fax Number:
619-697-9532
Provider Enumeration Date:
09/21/2008