Provider First Line Business Practice Location Address:
3969 4TH AVE STE 208
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:
92103-3165
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-849-5777
Provider Business Practice Location Address Fax Number:
619-849-5776
Provider Enumeration Date:
01/29/2007