Provider First Line Business Practice Location Address:
120 C AVENUE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
CORONADO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-435-6231
Provider Business Practice Location Address Fax Number:
619-435-4447
Provider Enumeration Date:
07/21/2008