Provider First Line Business Practice Location Address:
12625 HIGH BLUFF DRIVE
Provider Second Line Business Practice Location Address:
SUITE 101, RM 6
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92130-2053
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-948-2577
Provider Business Practice Location Address Fax Number:
816-339-3952
Provider Enumeration Date:
07/05/2007