Provider First Line Business Practice Location Address:
5020 BALTIMORE DR STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA MESA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91942-0692
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-460-0180
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/07/2022