Provider First Line Business Practice Location Address:
5671 BALBOA 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:
92111-2705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-800-2880
Provider Business Practice Location Address Fax Number:
619-569-2590
Provider Enumeration Date:
03/26/2014