Provider First Line Business Practice Location Address:
4024 IBIS ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92103-1840
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-296-6757
Provider Business Practice Location Address Fax Number:
619-287-3174
Provider Enumeration Date:
03/05/2007