Provider First Line Business Practice Location Address:
12264 EL CAMINO REAL
Provider Second Line Business Practice Location Address:
SUITE 111
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92130-3058
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-509-1259
Provider Business Practice Location Address Fax Number:
858-509-0912
Provider Enumeration Date:
08/30/2006