Provider First Line Business Practice Location Address:
3304 IDLEWILD WAY
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:
92117-3508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-270-8213
Provider Business Practice Location Address Fax Number:
858-270-8216
Provider Enumeration Date:
12/11/2015