Provider First Line Business Practice Location Address:
1119 28TH ST
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:
92102-2203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-233-7281
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/15/2006