Provider First Line Business Practice Location Address:
1539 GARNETT 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:
92109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-762-4632
Provider Business Practice Location Address Fax Number:
866-675-5593
Provider Enumeration Date:
05/12/2011