Provider First Line Business Practice Location Address:
6540 LUSK BLVD STE C139
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:
92121-2696
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-337-4096
Provider Business Practice Location Address Fax Number:
858-348-8091
Provider Enumeration Date:
02/24/2015