Provider First Line Business Practice Location Address:
4002 PARK BLVD STE E
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:
92103-2600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-296-2015
Provider Business Practice Location Address Fax Number:
619-296-2017
Provider Enumeration Date:
07/11/2006