Provider First Line Business Practice Location Address:
5465 LAKE MURRAY BLVD
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:
91942
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-466-7633
Provider Business Practice Location Address Fax Number:
619-466-5545
Provider Enumeration Date:
11/09/2006