Provider First Line Business Practice Location Address:
3639 MIDWAY DR
Provider Second Line Business Practice Location Address:
SUITE B286
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92110-5254
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-724-1747
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/18/2013