Provider First Line Business Practice Location Address:
1252 BROADWAY STE I
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:
92021-4904
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-375-1733
Provider Business Practice Location Address Fax Number:
619-684-6078
Provider Enumeration Date:
10/29/2014