Provider First Line Business Practice Location Address:
1707 GRAND AVE STE 2
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:
92109-4469
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-866-4545
Provider Business Practice Location Address Fax Number:
858-273-6702
Provider Enumeration Date:
02/23/2007