Provider First Line Business Practice Location Address:
1220 ROSECRANS ST STE 257
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:
92106-2674
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-807-6142
Provider Business Practice Location Address Fax Number:
866-608-9676
Provider Enumeration Date:
10/15/2019