Provider First Line Business Practice Location Address:
3928 ILLINOIS ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92104-3058
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-515-2588
Provider Business Practice Location Address Fax Number:
619-269-8349
Provider Enumeration Date:
02/08/2016