Provider First Line Business Practice Location Address:
4166 MONROE AVE
Provider Second Line Business Practice Location Address:
UNIT #1
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92116-4773
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-550-0059
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/22/2007