Provider First Line Business Practice Location Address:
5222 BALBOA AVE
Provider Second Line Business Practice Location Address:
SUITE# 73
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92117-6904
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-507-7897
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/22/2007