Provider First Line Business Practice Location Address:
410 DICKINSON 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:
92103-6902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-422-7377
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/24/2008