Provider First Line Business Practice Location Address:
3004 KALMIA 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:
92104-5464
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-303-4252
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/02/2011