Provider First Line Business Practice Location Address:
6190 FAIRMOUNT AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92120-3428
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-285-5040
Provider Business Practice Location Address Fax Number:
619-285-5045
Provider Enumeration Date:
06/09/2005