Provider First Line Business Practice Location Address:
4636 MISSION GORGE PL
Provider Second Line Business Practice Location Address:
STE 103-C
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92120-4151
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-822-2674
Provider Business Practice Location Address Fax Number:
619-255-2590
Provider Enumeration Date:
09/16/2010