Provider First Line Business Practice Location Address:
1212 S 43RD ST STE C
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:
92113-3454
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-263-7768
Provider Business Practice Location Address Fax Number:
619-262-5040
Provider Enumeration Date:
03/22/2007