Provider First Line Business Practice Location Address:
5955 MIRA MESA BLVD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92121-4304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-784-0500
Provider Business Practice Location Address Fax Number:
858-876-1529
Provider Enumeration Date:
09/24/2007