Provider First Line Business Practice Location Address:
3544 30TH ST
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:
92104-4120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-515-2300
Provider Business Practice Location Address Fax Number:
619-269-0674
Provider Enumeration Date:
05/04/2012