Provider First Line Business Practice Location Address:
205 WALNUT 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:
92103-4903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-295-2147
Provider Business Practice Location Address Fax Number:
619-295-2328
Provider Enumeration Date:
10/12/2006