Provider First Line Business Practice Location Address:
3030 CHILDREN'S WAY
Provider Second Line Business Practice Location Address:
STE 112
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92123-4226
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
325-677-2801
Provider Business Practice Location Address Fax Number:
325-677-9110
Provider Enumeration Date:
08/13/2006