Provider First Line Business Practice Location Address:
5575 LAKE PARK WAY
Provider Second Line Business Practice Location Address:
SUITE 100 UNIT 1
Provider Business Practice Location Address City Name:
LA MESA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91942-1664
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-729-8547
Provider Business Practice Location Address Fax Number:
619-881-0088
Provider Enumeration Date:
08/16/2011