Provider First Line Business Practice Location Address:
1940 54TH 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:
92105-5406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-839-7818
Provider Business Practice Location Address Fax Number:
323-566-6025
Provider Enumeration Date:
05/10/2012