Provider First Line Business Practice Location Address:
330 MOSS 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:
91911
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-628-2591
Provider Business Practice Location Address Fax Number:
619-628-2594
Provider Enumeration Date:
06/22/2007