Provider First Line Business Practice Location Address:
724 PROSPECT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA JOLLA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92037-4228
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-212-7315
Provider Business Practice Location Address Fax Number:
619-330-2245
Provider Enumeration Date:
12/31/2018