Provider First Line Business Practice Location Address:
4185 FAIRMOUNT AVE
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:
92105-1609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-584-1612
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/29/2008