Provider First Line Business Practice Location Address:
3434 MIDWAY DR
Provider Second Line Business Practice Location Address:
SUITE 2005A
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92110-4923
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-501-2195
Provider Business Practice Location Address Fax Number:
619-501-2176
Provider Enumeration Date:
04/02/2015