Provider First Line Business Practice Location Address:
13161 BLACK MOUNTAIN RD STE 5
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:
92129-2685
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-484-9202
Provider Business Practice Location Address Fax Number:
858-484-9630
Provider Enumeration Date:
03/01/2007