Provider First Line Business Practice Location Address:
3841 BASILONE ST UNIT 4
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:
92110-5409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-830-1159
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/02/2021