Provider First Line Business Practice Location Address:
5210 BALBOA AVE
Provider Second Line Business Practice Location Address:
SUITE A-2
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92117-6958
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-598-5842
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/16/2015