Provider First Line Business Practice Location Address:
4525 MISSION GORGE PL
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:
92120-4106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-228-8004
Provider Business Practice Location Address Fax Number:
619-228-8030
Provider Enumeration Date:
08/28/2006