Provider First Line Business Practice Location Address:
3405 KENYON ST
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92110-5003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-224-5371
Provider Business Practice Location Address Fax Number:
619-224-5489
Provider Enumeration Date:
07/29/2005