Provider First Line Business Practice Location Address:
4350 PALM AVE
Provider Second Line Business Practice Location Address:
STE 16
Provider Business Practice Location Address City Name:
LA MESA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91941-6505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-465-4349
Provider Business Practice Location Address Fax Number:
619-465-4349
Provider Enumeration Date:
10/26/2006