Provider First Line Business Practice Location Address:
5005 TEXAS ST
Provider Second Line Business Practice Location Address:
STE 203
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92108-3721
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-692-0727
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/12/2012