Provider First Line Business Practice Location Address:
5565 GROSSMONT CENTER DR
Provider Second Line Business Practice Location Address:
BLDG. 3 SUITE 256
Provider Business Practice Location Address City Name:
LA MESA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91942-3020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-462-3131
Provider Business Practice Location Address Fax Number:
619-462-1731
Provider Enumeration Date:
09/29/2006