Provider First Line Business Practice Location Address:
5663 BALBOA AVE # 115
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:
92111-2705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-871-7811
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/29/2010