Provider First Line Business Practice Location Address:
3540 MISSION BLVD
Provider Second Line Business Practice Location Address:
APT 3
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92109-7427
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-316-4755
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/14/2007