Provider First Line Business Practice Location Address:
420 SPRUCE 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:
92103-5800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-291-5266
Provider Business Practice Location Address Fax Number:
619-291-0124
Provider Enumeration Date:
08/31/2006