Provider First Line Business Practice Location Address:
3990 OLD TOWN AVE
Provider Second Line Business Practice Location Address:
SUITE 209A
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92110-2930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-294-9180
Provider Business Practice Location Address Fax Number:
619-298-9151
Provider Enumeration Date:
12/11/2006