Provider First Line Business Practice Location Address:
2707 CONGRESS ST STE 1R
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:
92110-2764
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-299-3161
Provider Business Practice Location Address Fax Number:
619-900-7779
Provider Enumeration Date:
04/22/2019