Provider First Line Business Practice Location Address:
3080 WING ST
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:
92110-4745
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-254-1017
Provider Business Practice Location Address Fax Number:
858-279-5303
Provider Enumeration Date:
10/26/2006