Provider First Line Business Practice Location Address:
3990 OLD TOWN AVE STE A109
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:
92110-2974
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-269-1056
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/15/2008