Provider First Line Business Practice Location Address:
3344 4TH 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:
92103-5704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-370-1714
Provider Business Practice Location Address Fax Number:
619-293-3275
Provider Enumeration Date:
07/20/2011