Provider First Line Business Practice Location Address:
1535 GRAND AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
SAN MARCOS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92078-2465
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-736-4148
Provider Business Practice Location Address Fax Number:
760-736-8246
Provider Enumeration Date:
10/16/2006