Provider First Line Business Practice Location Address:
3913 INGRAHAM ST
Provider Second Line Business Practice Location Address:
U 201
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92109-5911
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-212-6841
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/04/2008