Provider First Line Business Practice Location Address:
956 10TH AVE
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:
92101-6526
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-233-1311
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/19/2006