Provider First Line Business Practice Location Address:
5663 BALBOA AVE
Provider Second Line Business Practice Location Address:
UNIT 238
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92111-2705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-217-5073
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/09/2010