Provider First Line Business Practice Location Address:
1203 2ND ST
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:
92118-1417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-437-6600
Provider Business Practice Location Address Fax Number:
619-437-6603
Provider Enumeration Date:
04/17/2007