Provider First Line Business Practice Location Address:
4492 CAMINO DE LA PLZ
Provider Second Line Business Practice Location Address:
SUITE 163
Provider Business Practice Location Address City Name:
SAN YSIDRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92173-3003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-407-7911
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/23/2009