Provider First Line Business Practice Location Address:
3990 OLD TOWN AVE
Provider Second Line Business Practice Location Address:
STE. A-208
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92110-2930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-537-9345
Provider Business Practice Location Address Fax Number:
619-269-9245
Provider Enumeration Date:
06/20/2011