Provider First Line Business Practice Location Address:
2448 HISTORIC DECATUR RD
Provider Second Line Business Practice Location Address:
SUITE 130
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-398-2960
Provider Business Practice Location Address Fax Number:
619-398-2970
Provider Enumeration Date:
07/12/2005