Provider First Line Business Practice Location Address:
3719 LOUISIANA ST
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:
92104-3312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-368-3408
Provider Business Practice Location Address Fax Number:
619-299-4775
Provider Enumeration Date:
11/21/2006