Provider First Line Business Practice Location Address:
9779 W CANYON TER UNIT 1
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:
92123-4680
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-279-1740
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/01/2010