Provider First Line Business Practice Location Address:
105 W SPRUCE ST APT C
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:
92103-5555
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-920-6799
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/14/2021