Provider First Line Business Practice Location Address:
4540 KANSAS ST APT 2
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:
92116-4210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-615-0439
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/31/2008