Provider First Line Business Practice Location Address:
1854 CORONADO AVE
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:
92154-2007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-424-8612
Provider Business Practice Location Address Fax Number:
619-424-6331
Provider Enumeration Date:
10/19/2009