Provider First Line Business Practice Location Address:
1919 GRAND AVE STE 1E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92109-4578
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-270-5454
Provider Business Practice Location Address Fax Number:
858-270-5509
Provider Enumeration Date:
08/29/2006