Provider First Line Business Practice Location Address:
1052 DENNERY RD
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:
92154-8495
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-693-9042
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/20/2012