Provider First Line Business Practice Location Address:
5757 GAINES ST
Provider Second Line Business Practice Location Address:
APT. D
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92110-1763
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-272-4376
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/30/2011