Provider First Line Business Practice Location Address:
3990 OLD TOWN AVE STE A208
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92110-2967
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-786-0674
Provider Business Practice Location Address Fax Number:
619-789-0449
Provider Enumeration Date:
01/04/2007