Provider First Line Business Practice Location Address:
402 W BROADWAY STE 200
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:
92101-3542
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-539-7112
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/12/2010