Provider First Line Business Practice Location Address:
1729 1/2 OLIVER 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:
92109-5429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-775-4101
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/09/2013