Provider First Line Business Practice Location Address:
1621 LA PLAYA AVE
Provider Second Line Business Practice Location Address:
#15
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92109-6402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-207-8847
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/14/2016