Provider First Line Business Practice Location Address:
3821 RAY 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:
92104-3622
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-481-4512
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/28/2015