Provider First Line Business Practice Location Address:
305 WALNUT 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:
92103-4904
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-291-1181
Provider Business Practice Location Address Fax Number:
619-291-0316
Provider Enumeration Date:
02/28/2007