Provider First Line Business Practice Location Address:
9683 TIERRA GRANDE ST
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92126-6503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-695-2101
Provider Business Practice Location Address Fax Number:
858-695-2208
Provider Enumeration Date:
09/23/2005