Provider First Line Business Practice Location Address:
9606 TIERRA GRANDE ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92126-6501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-390-0373
Provider Business Practice Location Address Fax Number:
760-747-0817
Provider Enumeration Date:
06/25/2009