Provider First Line Business Practice Location Address:
6037 LA GRANADA PMB 1223
Provider Second Line Business Practice Location Address:
PMB 1223
Provider Business Practice Location Address City Name:
RANCHO SANTA FE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92067-1223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-756-5475
Provider Business Practice Location Address Fax Number:
858-756-7639
Provider Enumeration Date:
12/14/2005