Provider First Line Business Practice Location Address:
4002 30TH ST
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:
92104-2602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-284-8877
Provider Business Practice Location Address Fax Number:
619-274-8893
Provider Enumeration Date:
10/25/2005