Provider First Line Business Practice Location Address:
250 BROADWAY
Provider Second Line Business Practice Location Address:
T-0304
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-402-0001
Provider Business Practice Location Address Fax Number:
619-212-7809
Provider Enumeration Date:
06/09/2011