Provider First Line Business Practice Location Address:
6071 VIA REGLA
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:
92122-3924
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-444-5917
Provider Business Practice Location Address Fax Number:
619-444-1740
Provider Enumeration Date:
08/30/2006