Provider First Line Business Practice Location Address:
4323 PALM AVE
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
LA MESA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91941-6528
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-462-9933
Provider Business Practice Location Address Fax Number:
619-462-0112
Provider Enumeration Date:
11/28/2006