Provider First Line Business Practice Location Address:
2406 ULRIC ST
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:
92111-6040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-278-9393
Provider Business Practice Location Address Fax Number:
858-278-5393
Provider Enumeration Date:
07/06/2006