Provider First Line Business Practice Location Address:
3849 SHASTA ST
Provider Second Line Business Practice Location Address:
# 9
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92109-6536
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-692-6469
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/30/2006