Provider First Line Business Practice Location Address:
9636 TIERRA GRANDE ST STE 105
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:
92126-6502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-549-4511
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/24/2006