Provider First Line Business Practice Location Address:
1809 NATIONAL AVENUE
Provider Second Line Business Practice Location Address:
6TH FLOOR, CTR12
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-906-4623
Provider Business Practice Location Address Fax Number:
619-906-4564
Provider Enumeration Date:
12/27/2007