Provider First Line Business Practice Location Address:
4276 54TH PL STE D
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:
92115-6011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-281-1229
Provider Business Practice Location Address Fax Number:
619-265-0566
Provider Enumeration Date:
01/18/2007