Provider First Line Business Practice Location Address:
2645 1ST 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:
92103-6506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-239-7516
Provider Business Practice Location Address Fax Number:
619-239-7606
Provider Enumeration Date:
11/27/2007