Provider First Line Business Practice Location Address:
9663 TIERRA GRANDE ST
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92126-4568
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-695-2021
Provider Business Practice Location Address Fax Number:
858-695-2712
Provider Enumeration Date:
06/16/2006