Provider First Line Business Practice Location Address:
12660 CARMEL COUNTRY RD UNIT 83
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:
92130-3185
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-764-4235
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/01/2007