Provider First Line Business Practice Location Address:
430 NUTMEG ST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92103-6260
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-291-9108
Provider Business Practice Location Address Fax Number:
619-697-5627
Provider Enumeration Date:
12/27/2006