Provider First Line Business Practice Location Address:
4002 PARK BLVD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92103-2600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-294-9852
Provider Business Practice Location Address Fax Number:
619-291-2424
Provider Enumeration Date:
04/11/2007