Provider First Line Business Practice Location Address:
1344 EDGEMONT 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:
92102-1741
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-392-4313
Provider Business Practice Location Address Fax Number:
619-281-2295
Provider Enumeration Date:
08/19/2008