Provider First Line Business Practice Location Address:
2477 CONGRESS 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:
92110-2820
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-729-4931
Provider Business Practice Location Address Fax Number:
760-536-9136
Provider Enumeration Date:
10/03/2006