Provider First Line Business Practice Location Address:
4143 HAMILTON ST APT 3
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:
92104-1704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-363-2708
Provider Business Practice Location Address Fax Number:
619-566-4436
Provider Enumeration Date:
02/15/2007