Provider First Line Business Practice Location Address:
1706 5TH AVE
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92101-2700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-232-0783
Provider Business Practice Location Address Fax Number:
619-232-0784
Provider Enumeration Date:
03/27/2007