Provider First Line Business Practice Location Address:
3434 MIDWAY DR
Provider Second Line Business Practice Location Address:
1008
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92110-4923
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-273-8885
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/03/2011