Provider First Line Business Practice Location Address:
5080 SHOREHAM PL
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92122-5930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-272-2662
Provider Business Practice Location Address Fax Number:
858-272-2661
Provider Enumeration Date:
11/07/2010