Provider First Line Business Practice Location Address:
9606 TIERRA GRANDE STREET
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-695-9415
Provider Business Practice Location Address Fax Number:
858-695-9412
Provider Enumeration Date:
12/04/2006