Provider First Line Business Practice Location Address:
5565 GROSSMONT CENTER DRIVE #1-119
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-464-3153
Provider Business Practice Location Address Fax Number:
619-464-3429
Provider Enumeration Date:
11/15/2006