Provider First Line Business Practice Location Address:
4003 GROS VENTRE AVE
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:
92117-4641
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-989-2728
Provider Business Practice Location Address Fax Number:
858-483-0809
Provider Enumeration Date:
01/25/2006