Provider First Line Business Practice Location Address:
1224 10TH STREET
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
CORONADO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92118-3420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-437-4812
Provider Business Practice Location Address Fax Number:
619-437-1881
Provider Enumeration Date:
10/03/2006