Provider First Line Business Practice Location Address:
1252 BROADWAY
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
EL CAJON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92021-4901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-504-4996
Provider Business Practice Location Address Fax Number:
619-464-1157
Provider Enumeration Date:
10/16/2006