Provider First Line Business Practice Location Address:
3957 30TH ST # 517
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:
92104-3004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-847-1018
Provider Business Practice Location Address Fax Number:
619-291-3441
Provider Enumeration Date:
05/23/2007