Provider First Line Business Practice Location Address:
10633 CANYON LAKE DR
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:
92131-1212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-689-8285
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/25/2007