Provider First Line Business Practice Location Address:
165 S 1ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL CAJON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92019-4795
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-312-0347
Provider Business Practice Location Address Fax Number:
619-749-5480
Provider Enumeration Date:
08/05/2011