Provider First Line Business Practice Location Address:
319 LAUREL 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:
92101-1630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-762-4542
Provider Business Practice Location Address Fax Number:
619-305-0218
Provider Enumeration Date:
03/13/2020