Provider First Line Business Practice Location Address:
2917 C ST
Provider Second Line Business Practice Location Address:
UNIT 187
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92102-2296
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-208-8939
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/01/2012