Provider First Line Business Practice Location Address:
5500 CAMPANILE DR
Provider Second Line Business Practice Location Address:
SAN DIEGO STATE UNIVERSITY-DEPT OF ATHLETICS
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92182-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-594-8371
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/05/2010