Provider First Line Business Practice Location Address:
4458 MARYLAND ST
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:
92116-3901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-807-4737
Provider Business Practice Location Address Fax Number:
619-260-9006
Provider Enumeration Date:
05/23/2007