Provider First Line Business Practice Location Address:
12395 EL CAMINO REAL
Provider Second Line Business Practice Location Address:
SUITE 311
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92130-3085
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-481-3391
Provider Business Practice Location Address Fax Number:
858-481-9065
Provider Enumeration Date:
10/19/2006