Provider First Line Business Practice Location Address:
4412 UPLAND ST
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:
91941-6517
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-532-7355
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/24/2007