Provider First Line Business Practice Location Address:
5379 BALBOA AVE
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:
92117-6913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-405-8926
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/23/2013