Provider First Line Business Practice Location Address:
12032 FAIRHOPE RD
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:
92128-2050
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-333-6764
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/10/2012