Provider First Line Business Practice Location Address:
1809 NATIONAL AVE
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:
92113-2113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-515-2323
Provider Business Practice Location Address Fax Number:
619-234-2447
Provider Enumeration Date:
07/31/2006