Provider First Line Business Practice Location Address:
4247 PARK BLVD
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:
92103-2512
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-546-0464
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/15/2011