Provider First Line Business Practice Location Address:
4024 IBIS STREET
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92103-1840
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-574-0110
Provider Business Practice Location Address Fax Number:
619-698-5609
Provider Enumeration Date:
10/23/2007