Provider First Line Business Practice Location Address:
NHRC CODE 25
Provider Second Line Business Practice Location Address:
BOX 85122
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92186-5122
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-553-8097
Provider Business Practice Location Address Fax Number:
619-553-7601
Provider Enumeration Date:
08/01/2005