Provider First Line Business Practice Location Address:
9524 KEARNY VILLA RD
Provider Second Line Business Practice Location Address:
SUITE 111
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92126-4582
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-693-3196
Provider Business Practice Location Address Fax Number:
858-695-9201
Provider Enumeration Date:
07/31/2006