Provider First Line Business Practice Location Address:
4194 CONVOY ST
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:
92111-3702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-569-1918
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/16/2007