Provider First Line Business Practice Location Address:
1040 UNIVERSITY AVE STE B209A
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:
92103-7328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-299-1100
Provider Business Practice Location Address Fax Number:
619-299-7156
Provider Enumeration Date:
09/20/2006