Provider First Line Business Practice Location Address:
138 B AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORONADO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92118-1511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-857-8346
Provider Business Practice Location Address Fax Number:
619-435-1952
Provider Enumeration Date:
10/13/2005