Provider First Line Business Practice Location Address:
12580 CARMEL CREEK RD UNIT 48
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:
92130-2379
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-414-8217
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/20/2007