Provider First Line Business Practice Location Address:
3033 5TH AVE
Provider Second Line Business Practice Location Address:
SUITE 410
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92103-5856
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-228-9668
Provider Business Practice Location Address Fax Number:
619-228-9685
Provider Enumeration Date:
08/17/2006