Provider First Line Business Practice Location Address:
4646 CONVOY ST
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92111-2315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-278-6288
Provider Business Practice Location Address Fax Number:
858-278-6188
Provider Enumeration Date:
07/26/2006