Provider First Line Business Practice Location Address:
501 W BROADWAY
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:
92101-3536
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-488-3597
Provider Business Practice Location Address Fax Number:
858-724-1747
Provider Enumeration Date:
10/07/2011