Provider First Line Business Practice Location Address:
3405 KENYON ST STE 513
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:
92110-5008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-226-1877
Provider Business Practice Location Address Fax Number:
619-226-0482
Provider Enumeration Date:
06/27/2012