Provider First Line Business Practice Location Address:
5106 FEDERAL BLVD
Provider Second Line Business Practice Location Address:
STE 205
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92105-5453
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-266-1181
Provider Business Practice Location Address Fax Number:
619-266-1191
Provider Enumeration Date:
12/22/2011