Provider First Line Business Practice Location Address:
4153 1ST 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:
92103-2047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-683-7671
Provider Business Practice Location Address Fax Number:
877-471-6899
Provider Enumeration Date:
04/16/2007