Provider First Line Business Practice Location Address:
9500 GILMAN DR DEPT 664
Provider Second Line Business Practice Location Address:
UNIVERSITY OF CALIFORNIA SAN DIEGO
Provider Business Practice Location Address City Name:
LA JOLLA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92093-0664
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-206-9962
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/13/2012