Provider First Line Business Practice Location Address:
6153FAIRMOUNT AVE
Provider Second Line Business Practice Location Address:
SUITE 260
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-481-3790
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/14/2011