Provider First Line Business Practice Location Address:
3692 MIDWAY DR
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:
92110-5201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-758-6253
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/07/2007