Provider First Line Business Practice Location Address:
420 SPRUCE ST STE C
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:
92103-5859
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-298-9839
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/20/2007