Provider First Line Business Practice Location Address:
5222 BALBOA AVE
Provider Second Line Business Practice Location Address:
SUITE 42
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92117-6904
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-268-0702
Provider Business Practice Location Address Fax Number:
858-268-0374
Provider Enumeration Date:
10/10/2006