Provider First Line Business Practice Location Address:
2359 ULRIC 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:
92111-6402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-268-4933
Provider Business Practice Location Address Fax Number:
858-268-0244
Provider Enumeration Date:
04/25/2007