Provider First Line Business Practice Location Address:
2903 29TH 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:
92104-4912
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-281-7447
Provider Business Practice Location Address Fax Number:
619-281-9468
Provider Enumeration Date:
07/17/2009