Provider First Line Business Practice Location Address:
6204 COLLEGE AVE
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:
92120-3006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-300-4366
Provider Business Practice Location Address Fax Number:
949-812-6657
Provider Enumeration Date:
08/27/2012