Provider First Line Business Practice Location Address:
8148 GENESEE AVE APT 139
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:
92122-1462
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-728-2150
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/30/2012