Provider First Line Business Practice Location Address:
3860 CONVOY ST
Provider Second Line Business Practice Location Address:
SUITE 119
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92111-3748
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-349-2088
Provider Business Practice Location Address Fax Number:
858-565-0974
Provider Enumeration Date:
06/21/2011