Provider First Line Business Practice Location Address:
4400 PALM AVE
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
LA MESA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91941-6524
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-469-7827
Provider Business Practice Location Address Fax Number:
619-469-7833
Provider Enumeration Date:
08/19/2005