Provider First Line Business Practice Location Address:
9474 KEARNY VILLA RD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92126-4595
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-494-5091
Provider Business Practice Location Address Fax Number:
619-881-0408
Provider Enumeration Date:
07/31/2012