Provider First Line Business Practice Location Address:
3990 OLD TOWN AVE
Provider Second Line Business Practice Location Address:
SUITE A208
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:
619-764-6516
Provider Business Practice Location Address Fax Number:
619-880-5950
Provider Enumeration Date:
12/27/2016