Provider First Line Business Practice Location Address:
4967 NEWPORT AVE
Provider Second Line Business Practice Location Address:
SUITE 12
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92107-3167
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-246-8240
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/15/2013