Provider First Line Business Practice Location Address:
3453 INGRAHAM ST # 96
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:
92109-6713
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-575-4687
Provider Business Practice Location Address Fax Number:
619-575-1412
Provider Enumeration Date:
03/06/2007