Provider First Line Business Practice Location Address:
3131 DICKENS ST
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:
92106-2623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-464-1372
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/20/2012