Provider First Line Business Practice Location Address:
4452 PARK BLVD
Provider Second Line Business Practice Location Address:
212
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92116-4051
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-775-2501
Provider Business Practice Location Address Fax Number:
619-684-5459
Provider Enumeration Date:
02/27/2007