Provider First Line Business Practice Location Address:
306 WALNUT AVE
Provider Second Line Business Practice Location Address:
SUITE #29
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92103-4978
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-298-7115
Provider Business Practice Location Address Fax Number:
619-298-7163
Provider Enumeration Date:
01/02/2007