Provider First Line Business Practice Location Address:
5119 GARFIELD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA MESA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91941-5103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-460-4055
Provider Business Practice Location Address Fax Number:
619-460-5148
Provider Enumeration Date:
10/18/2005