Provider First Line Business Practice Location Address:
9663 TIERRA GRANDE ST
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:
92126-4569
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-695-2243
Provider Business Practice Location Address Fax Number:
858-452-2725
Provider Enumeration Date:
09/27/2006