Provider First Line Business Practice Location Address:
3990 OLD TOWN AVE
Provider Second Line Business Practice Location Address:
STE 209A
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92110-2967
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-615-5065
Provider Business Practice Location Address Fax Number:
619-294-9181
Provider Enumeration Date:
02/23/2007