Provider First Line Business Practice Location Address:
4700 SPRING ST STE 204
Provider Second Line Business Practice Location Address:
#204
Provider Business Practice Location Address City Name:
LA MESA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91941-5273
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-583-0747
Provider Business Practice Location Address Fax Number:
619-583-2729
Provider Enumeration Date:
09/14/2005