Provider First Line Business Practice Location Address:
1664 BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL CAJON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92021-5201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-579-8685
Provider Business Practice Location Address Fax Number:
619-682-4096
Provider Enumeration Date:
11/01/2006