Provider First Line Business Practice Location Address:
12778 RANCHO PENASQUITOS BLVD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92129-2946
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-780-9794
Provider Business Practice Location Address Fax Number:
858-780-9690
Provider Enumeration Date:
06/15/2011