Provider First Line Business Practice Location Address:
3795 30TH ST STE A
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:
92104-3631
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-260-1958
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/20/2007