Provider First Line Business Practice Location Address:
5565 GROSSMONT CENTER DR
Provider Second Line Business Practice Location Address:
BLD 1 STE 129
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:
619-463-4486
Provider Business Practice Location Address Fax Number:
619-463-6553
Provider Enumeration Date:
01/30/2007