Provider First Line Business Practice Location Address:
2772 4TH AVE
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:
92103-6206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-295-6067
Provider Business Practice Location Address Fax Number:
619-295-6047
Provider Enumeration Date:
07/20/2006