Provider First Line Business Practice Location Address:
4527 COLLEGE AVE
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:
92115-4010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-265-9336
Provider Business Practice Location Address Fax Number:
619-583-2676
Provider Enumeration Date:
07/29/2005