Provider First Line Business Practice Location Address:
6507 TANGLEWOOD RD
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:
92111-4127
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-920-0826
Provider Business Practice Location Address Fax Number:
858-560-1368
Provider Enumeration Date:
08/15/2007