Provider First Line Business Practice Location Address:
4915 MERCURY ST
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:
92111-1703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-698-6808
Provider Business Practice Location Address Fax Number:
619-698-1128
Provider Enumeration Date:
08/31/2006