Provider First Line Business Practice Location Address:
3101 4TH 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:
92103-5802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-764-0980
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/29/2008