Provider First Line Business Practice Location Address:
3320 KEMPER ST
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:
92110-4903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-758-6205
Provider Business Practice Location Address Fax Number:
619-758-6209
Provider Enumeration Date:
02/23/2007