Provider First Line Business Practice Location Address:
5722 UNIVERSITY AVE APT 13
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:
92115-6285
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-287-2147
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/23/2007