Provider First Line Business Practice Location Address:
3521 LOUISIANA 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:
92104-4022
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-720-6315
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/14/2023