Provider First Line Business Practice Location Address:
2206 BALBOA 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:
92109-4735
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-866-6688
Provider Business Practice Location Address Fax Number:
858-866-5644
Provider Enumeration Date:
02/11/2011