Provider First Line Business Practice Location Address:
2172 BLACKMORE CT
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:
92109-1420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-889-8444
Provider Business Practice Location Address Fax Number:
858-272-3227
Provider Enumeration Date:
09/30/2009