Provider First Line Business Practice Location Address:
4060 FAIRMOUNT AVE STE 120
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:
92105-1608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-269-1299
Provider Business Practice Location Address Fax Number:
619-961-0812
Provider Enumeration Date:
09/22/2005