Provider First Line Business Practice Location Address:
850 STATE ST
Provider Second Line Business Practice Location Address:
UNIT 115
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92101-6046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-955-5625
Provider Business Practice Location Address Fax Number:
619-955-5769
Provider Enumeration Date:
05/19/2007