Provider First Line Business Practice Location Address:
3240 OLIVE ST
Provider Second Line Business Practice Location Address:
APARTMENT #50
Provider Business Practice Location Address City Name:
LEMON GROVE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91945-1768
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-248-3835
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/15/2007