Provider First Line Business Practice Location Address:
5004 MAYNARD ST
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:
92122-3934
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-450-1965
Provider Business Practice Location Address Fax Number:
858-450-1397
Provider Enumeration Date:
03/29/2007