Provider First Line Business Practice Location Address:
4851 BRIGHTON AVE APT G
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:
92107-2583
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-284-7132
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/31/2023