Provider First Line Business Practice Location Address:
3636 4TH AVE
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92103-4280
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-220-7680
Provider Business Practice Location Address Fax Number:
619-220-7682
Provider Enumeration Date:
07/21/2006