Provider First Line Business Practice Location Address:
1959 GRAND AVE STE A
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:
92109-4511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-229-0168
Provider Business Practice Location Address Fax Number:
858-581-5788
Provider Enumeration Date:
07/20/2006