Provider First Line Business Practice Location Address:
4026 HAWK ST STE B
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:
92103-1862
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-692-4038
Provider Business Practice Location Address Fax Number:
619-234-7272
Provider Enumeration Date:
08/30/2006