Provider First Line Business Practice Location Address:
8312 LAKE MURRAY BLVD
Provider Second Line Business Practice Location Address:
STE C
Provider Business Practice Location Address City Name:
SAN DIEGO CA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92119
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-464-2076
Provider Business Practice Location Address Fax Number:
619-464-8959
Provider Enumeration Date:
12/13/2011