Provider First Line Business Practice Location Address:
614 5TH AVE STE A
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:
92101-6964
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-231-2668
Provider Business Practice Location Address Fax Number:
619-231-4133
Provider Enumeration Date:
08/09/2006