Provider First Line Business Practice Location Address:
1174 BROADWAY
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
EL CAJON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92021-7418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-444-9481
Provider Business Practice Location Address Fax Number:
619-444-1348
Provider Enumeration Date:
09/20/2006