Provider First Line Business Practice Location Address:
1231 MANZANA WAY
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:
92139-1440
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-840-5413
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/23/2011