Provider First Line Business Practice Location Address:
5803 RILEY ST
Provider Second Line Business Practice Location Address:
UNIT 2
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92110-1729
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-875-7052
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/31/2012