Provider First Line Business Practice Location Address:
4428 GLACIER 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:
92120-3304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-466-3246
Provider Business Practice Location Address Fax Number:
619-466-4134
Provider Enumeration Date:
07/10/2006