Provider First Line Business Practice Location Address:
3156 SPORTS ARENA BLVD.
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-523-6767
Provider Business Practice Location Address Fax Number:
619-523-6769
Provider Enumeration Date:
12/11/2006