Provider First Line Business Practice Location Address:
4394 30TH 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:
92104-1314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-344-3802
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/11/2007