Provider First Line Business Practice Location Address:
4096 PARK BLVD.
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92103-2620
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-260-0865
Provider Business Practice Location Address Fax Number:
619-260-0640
Provider Enumeration Date:
07/03/2006