Provider First Line Business Practice Location Address:
2630 1ST 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:
92103-6599
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-234-2158
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/20/2019