Provider First Line Business Practice Location Address:
810 EMERALD 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:
92109-2712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-925-1879
Provider Business Practice Location Address Fax Number:
858-274-8700
Provider Enumeration Date:
12/19/2011