Provider First Line Business Practice Location Address:
4545 PARK BLVD
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92116-2667
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-402-3056
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/20/2006