Provider First Line Business Practice Location Address:
4060 4TH AVE
Provider Second Line Business Practice Location Address:
#105
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92103-2116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-299-5246
Provider Business Practice Location Address Fax Number:
619-299-5751
Provider Enumeration Date:
12/19/2005