Provider First Line Business Practice Location Address:
3990 OLD TOWN AVE
Provider Second Line Business Practice Location Address:
SUITE C201
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92110-2930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-278-2424
Provider Business Practice Location Address Fax Number:
619-294-9405
Provider Enumeration Date:
05/11/2012