Provider First Line Business Practice Location Address:
1845 LOGAN AVE
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:
92113-2111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-906-4621
Provider Business Practice Location Address Fax Number:
619-234-8884
Provider Enumeration Date:
07/11/2011