Provider First Line Business Practice Location Address:
250 BROADWAY
Provider Second Line Business Practice Location Address:
TARGET 231
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-402-0001
Provider Business Practice Location Address Fax Number:
619-402-0001
Provider Enumeration Date:
09/16/2011