Provider First Line Business Practice Location Address:
2707 CONGRESS ST
Provider Second Line Business Practice Location Address:
SUITE 2A
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92110-2758
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-234-2221
Provider Business Practice Location Address Fax Number:
619-234-9232
Provider Enumeration Date:
02/21/2006