Provider First Line Business Practice Location Address:
2630 1ST AVE
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92103-6599
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-866-4620
Provider Business Practice Location Address Fax Number:
619-324-1023
Provider Enumeration Date:
11/05/2012