Provider First Line Business Practice Location Address:
4348 54TH STREET
Provider Second Line Business Practice Location Address:
A
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92115-5300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-419-3469
Provider Business Practice Location Address Fax Number:
619-255-8867
Provider Enumeration Date:
08/04/2010