Provider First Line Business Practice Location Address:
1767 E MAIN ST
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:
92021-5219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-440-6516
Provider Business Practice Location Address Fax Number:
619-440-6547
Provider Enumeration Date:
05/30/2006