Provider First Line Business Practice Location Address:
4020 4TH AVE
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:
92103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-368-6749
Provider Business Practice Location Address Fax Number:
206-826-9137
Provider Enumeration Date:
09/18/2014