Provider First Line Business Practice Location Address:
804 FIRETHORN ST
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:
92154-2635
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-581-9764
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/17/2019