Provider First Line Business Practice Location Address:
6540 LUSK BLVD
Provider Second Line Business Practice Location Address:
STE C265
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92121-2767
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-412-4403
Provider Business Practice Location Address Fax Number:
858-412-5647
Provider Enumeration Date:
08/28/2012