Provider First Line Business Practice Location Address:
666 UPAS ST UNIT 1605
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:
92103-5036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-331-2155
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/03/2021