Provider First Line Business Practice Location Address:
2074 GARNET 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:
92109-3524
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-927-5889
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/24/2012