Provider First Line Business Practice Location Address:
4222 KANSAS ST UNIT 2
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:
92104-1802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
747-218-8409
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/29/2020