Provider First Line Business Practice Location Address:
4707 NEWPORT AVE
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:
92107-2204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-717-3062
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/25/2015