Provider First Line Business Practice Location Address:
889 DATE ST UNIT 534
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:
92101-8640
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-302-3206
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/16/2012