Provider First Line Business Practice Location Address:
5252 BALBOA AVE
Provider Second Line Business Practice Location Address:
SUITE 707
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92117-6906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-336-1710
Provider Business Practice Location Address Fax Number:
888-505-0963
Provider Enumeration Date:
11/06/2006