Provider First Line Business Practice Location Address:
230 W LAUREL ST
Provider Second Line Business Practice Location Address:
UNIT 703
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92101-1461
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-595-1564
Provider Business Practice Location Address Fax Number:
858-720-8285
Provider Enumeration Date:
04/16/2007