Provider First Line Business Practice Location Address:
400 CRAVEN ROAD
Provider Second Line Business Practice Location Address:
DEPARTMENT OF DERMATOLOGY
Provider Business Practice Location Address City Name:
SAN MARCOS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92078-4201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-510-4056
Provider Business Practice Location Address Fax Number:
760-510-4212
Provider Enumeration Date:
06/27/2005