Provider First Line Business Practice Location Address:
2535 KETTNER AVE
Provider Second Line Business Practice Location Address:
1A4
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CALIFORNIA
Provider Business Practice Location Address Postal Code:
92101
Provider Business Practice Location Address Country Code:
UM
Provider Business Practice Location Address Telephone Number:
619-615-0701
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/27/2014