Provider First Line Business Practice Location Address:
4711 VISTA ST
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:
92116-2529
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-459-4210
Provider Business Practice Location Address Fax Number:
619-282-3100
Provider Enumeration Date:
04/07/2007