Provider First Line Business Practice Location Address:
1109 VAN NUYS ST
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:
92109-1253
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-660-3356
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/13/2011