Provider First Line Business Practice Location Address:
12517 LAKESHORE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKESIDE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92040-3103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-443-3843
Provider Business Practice Location Address Fax Number:
619-390-1810
Provider Enumeration Date:
09/27/2006