Provider First Line Business Practice Location Address:
1090 UNIVERSITY AVE
Provider Second Line Business Practice Location Address:
LOFT 202B
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92103-7307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-822-1660
Provider Business Practice Location Address Fax Number:
866-302-7589
Provider Enumeration Date:
11/05/2011