Provider First Line Business Practice Location Address:
1174 E MAIN ST SPC 143
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:
92021-7124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-201-8462
Provider Business Practice Location Address Fax Number:
619-201-8463
Provider Enumeration Date:
04/11/2006