Provider First Line Business Practice Location Address:
306 WALNUT AVE.
Provider Second Line Business Practice Location Address:
SUITE 36A
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-234-8245
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/23/2013