Provider First Line Business Practice Location Address:
2725 CONGRESS ST STE 1D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92110-2783
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-288-6866
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/23/2010