Provider First Line Business Practice Location Address:
4535 30TH ST
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92116-4212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-260-1958
Provider Business Practice Location Address Fax Number:
619-260-1983
Provider Enumeration Date:
09/14/2005