Provider First Line Business Practice Location Address:
1224 PROSPECT ST STE 110
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA JOLLA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92037-3633
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-459-5557
Provider Business Practice Location Address Fax Number:
858-454-6484
Provider Enumeration Date:
05/24/2007