Provider First Line Business Practice Location Address:
12307 POWAY RD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
POWAY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92064-4245
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-668-3390
Provider Business Practice Location Address Fax Number:
858-668-3397
Provider Enumeration Date:
06/05/2007