Provider First Line Business Practice Location Address:
4452 PARK BLVD
Provider Second Line Business Practice Location Address:
SUITE 309
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92116-4051
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-574-7525
Provider Business Practice Location Address Fax Number:
619-574-6969
Provider Enumeration Date:
02/06/2007