Provider First Line Business Practice Location Address:
4009 PARK BLVD
Provider Second Line Business Practice Location Address:
#14
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92103-2619
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-987-8391
Provider Business Practice Location Address Fax Number:
858-270-7128
Provider Enumeration Date:
03/14/2007