Provider First Line Business Practice Location Address:
BOX 153
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:
92136-5153
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-556-8475
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/30/2006