Provider First Line Business Practice Location Address:
11665 AVENA PL STE 204
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:
92128-2428
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-848-4028
Provider Business Practice Location Address Fax Number:
858-381-9769
Provider Enumeration Date:
07/14/2006