Provider First Line Business Practice Location Address:
1540 FERN ST
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:
92102-1521
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-236-9549
Provider Business Practice Location Address Fax Number:
619-234-0311
Provider Enumeration Date:
10/03/2006