Provider First Line Business Practice Location Address:
5252 BALBOA AVE
Provider Second Line Business Practice Location Address:
SUITE 503
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-252-3713
Provider Business Practice Location Address Fax Number:
619-810-0620
Provider Enumeration Date:
08/30/2006