Provider First Line Business Practice Location Address:
3760 CONVOY ST
Provider Second Line Business Practice Location Address:
SUITE 118
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92111-3742
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-884-1549
Provider Business Practice Location Address Fax Number:
858-693-8314
Provider Enumeration Date:
07/13/2006