Provider First Line Business Practice Location Address:
3262 ASHFORD ST UNIT H
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:
92111-5007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-468-2649
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/29/2016