Provider First Line Business Practice Location Address:
330 A ST
Provider Second Line Business Practice Location Address:
STE 152
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92101-4213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-512-9770
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/03/2013