Provider First Line Business Practice Location Address:
6026 BOUNTY 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:
92120-2923
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-805-9139
Provider Business Practice Location Address Fax Number:
866-304-7039
Provider Enumeration Date:
12/18/2006