Provider First Line Business Practice Location Address:
4535 30TH ST STE 115
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:
92116-4245
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
432-352-8315
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/22/2008