Provider First Line Business Practice Location Address:
8425 GRANT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA MESA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91941-5303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-464-3631
Provider Business Practice Location Address Fax Number:
619-464-3724
Provider Enumeration Date:
09/18/2007