Provider First Line Business Practice Location Address:
5252 BALBOA AVE STE 408
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:
92117-6939
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-203-2339
Provider Business Practice Location Address Fax Number:
920-364-2451
Provider Enumeration Date:
12/31/2014