Provider First Line Business Practice Location Address:
171 C. AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORONADO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92118-4411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-435-4229
Provider Business Practice Location Address Fax Number:
619-435-4275
Provider Enumeration Date:
11/11/2005