Provider First Line Business Practice Location Address:
1 CIVIC CENTER DR
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
SAN MARCOS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92069-2918
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-744-9120
Provider Business Practice Location Address Fax Number:
760-744-1654
Provider Enumeration Date:
07/19/2006