Provider First Line Business Practice Location Address:
4956 1/2 FIELD 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:
92110-2222
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-987-3997
Provider Business Practice Location Address Fax Number:
619-987-3997
Provider Enumeration Date:
12/01/2017