Provider First Line Business Practice Location Address:
4692 MISSION BLVD
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:
92109-2734
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-647-5072
Provider Business Practice Location Address Fax Number:
619-330-4782
Provider Enumeration Date:
06/26/2013