Provider First Line Business Practice Location Address:
9663 TIERRA GRANDE ST
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92126-4568
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-840-5045
Provider Business Practice Location Address Fax Number:
858-689-6979
Provider Enumeration Date:
11/22/2006