Provider First Line Business Practice Location Address:
7677 MISSION GORGE RD UNIT 142
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:
92120-1366
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-774-8154
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/03/2005