Provider First Line Business Practice Location Address:
699 14TH ST UNIT 442
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:
92101-7594
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-701-2261
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/30/2023