Provider First Line Business Practice Location Address:
10278 BLACK MOUNTAIN RD
Provider Second Line Business Practice Location Address:
173
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92126-3872
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-755-8956
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/15/2010