Provider First Line Business Practice Location Address:
1055 4TH AVE
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:
92101-4802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-232-1005
Provider Business Practice Location Address Fax Number:
619-232-1007
Provider Enumeration Date:
09/14/2006