Provider First Line Business Practice Location Address:
49620 BELUGA RD
Provider Second Line Business Practice Location Address:
BLDG 194, RM 111
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92152-6505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-553-1869
Provider Business Practice Location Address Fax Number:
619-553-6295
Provider Enumeration Date:
10/24/2016