Provider First Line Business Practice Location Address:
2705 W CANYON AVE
Provider Second Line Business Practice Location Address:
APPT. 115
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92123-4734
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-822-9269
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/21/2006