Provider First Line Business Practice Location Address:
13112 EVENING CREEK DR S
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-668-3447
Provider Business Practice Location Address Fax Number:
516-512-5301
Provider Enumeration Date:
06/08/2005