Provider First Line Business Practice Location Address:
214 DICKINSON STREET
Provider Second Line Business Practice Location Address:
BLDG CTF, ROOM C103
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92103-8467
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-543-2904
Provider Business Practice Location Address Fax Number:
619-543-7868
Provider Enumeration Date:
05/04/2007