Provider First Line Business Practice Location Address:
4698 CONVOY ST
Provider Second Line Business Practice Location Address:
STE 203
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92111-2331
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-565-2811
Provider Business Practice Location Address Fax Number:
858-565-2814
Provider Enumeration Date:
05/02/2007