Provider First Line Business Practice Location Address:
12264 EL CAMINO REAL
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92130-3058
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-832-8404
Provider Business Practice Location Address Fax Number:
888-374-2984
Provider Enumeration Date:
11/13/2006