Provider First Line Business Practice Location Address:
9580 BLACK MOUNTAIN RD
Provider Second Line Business Practice Location Address:
SUITE J
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92126-4522
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-536-8952
Provider Business Practice Location Address Fax Number:
858-536-8951
Provider Enumeration Date:
10/12/2005