Provider First Line Business Practice Location Address:
3156 SPORTS ARENA BOULEVARD
Provider Second Line Business Practice Location Address:
SUITE 106
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-687-0867
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/14/2014