Provider First Line Business Practice Location Address:
9625 BLACK MOUNTAIN RD
Provider Second Line Business Practice Location Address:
SUITE 302
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92126-4564
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-621-6363
Provider Business Practice Location Address Fax Number:
858-621-6366
Provider Enumeration Date:
03/18/2008