Provider First Line Business Practice Location Address:
918 ORANGE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORONADO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92118-2610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-435-4177
Provider Business Practice Location Address Fax Number:
619-435-1950
Provider Enumeration Date:
10/07/2006