Provider First Line Business Practice Location Address:
6540 LUSK BLVD
Provider Second Line Business Practice Location Address:
SUITE C159
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92121-2767
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-415-0122
Provider Business Practice Location Address Fax Number:
760-454-0444
Provider Enumeration Date:
01/03/2012