Provider First Line Business Practice Location Address:
3356 2ND AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92103-5636
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-269-1761
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/14/2007