Provider First Line Business Practice Location Address:
1130 2ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ENCINITAS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92024-5008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-943-9994
Provider Business Practice Location Address Fax Number:
760-943-1661
Provider Enumeration Date:
08/23/2006