Provider First Line Business Practice Location Address:
945 HORNBLEND ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92109-4057
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-925-1453
Provider Business Practice Location Address Fax Number:
858-657-0210
Provider Enumeration Date:
05/03/2007