Provider First Line Business Practice Location Address:
6494 EDMONTON 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:
92122-2513
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-717-2719
Provider Business Practice Location Address Fax Number:
858-408-2468
Provider Enumeration Date:
09/02/2005