Provider First Line Business Practice Location Address:
5480 BALTIMORE DR
Provider Second Line Business Practice Location Address:
SUITE 250
Provider Business Practice Location Address City Name:
LA MESA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91942-2020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-630-5113
Provider Business Practice Location Address Fax Number:
619-303-3306
Provider Enumeration Date:
07/16/2006