Provider First Line Business Practice Location Address:
1235 DIAMOND 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:
92109-2645
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-707-2052
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/01/2014