Provider First Line Business Practice Location Address:
5434 OLIVE ST UNIT A
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:
92105-5054
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-840-9440
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/17/2010