Provider First Line Business Practice Location Address:
5716 HARDY AVENUE
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:
92115-1314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-846-9686
Provider Business Practice Location Address Fax Number:
619-594-4315
Provider Enumeration Date:
06/12/2007