Provider First Line Business Practice Location Address:
4070 PORTE LA PAZ UNIT 20
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92122-4817
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-666-9715
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/21/2008