Provider First Line Business Practice Location Address:
4495 DALE AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
LA MESA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91941-6206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-465-4436
Provider Business Practice Location Address Fax Number:
619-465-4456
Provider Enumeration Date:
09/16/2015