Provider First Line Business Practice Location Address:
2725 CONGRESS ST
Provider Second Line Business Practice Location Address:
SUITE 2C
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92110-2757
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-977-3439
Provider Business Practice Location Address Fax Number:
619-688-1098
Provider Enumeration Date:
01/22/2010