Provider First Line Business Practice Location Address:
1775 LOCUST 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:
92106-1904
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-222-0531
Provider Business Practice Location Address Fax Number:
619-222-0678
Provider Enumeration Date:
05/21/2007