Provider First Line Business Practice Location Address:
611 K ST UNIT B
Provider Second Line Business Practice Location Address:
PMB#371
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92101-7091
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-207-2768
Provider Business Practice Location Address Fax Number:
760-557-2309
Provider Enumeration Date:
11/03/2006