Provider First Line Business Practice Location Address:
411 THORN ST
Provider Second Line Business Practice Location Address:
SUITE A 2
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92103-5700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-295-8945
Provider Business Practice Location Address Fax Number:
619-295-8998
Provider Enumeration Date:
02/08/2007