Provider First Line Business Practice Location Address:
3077 39TH 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:
92105-4012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-855-1228
Provider Business Practice Location Address Fax Number:
619-229-1178
Provider Enumeration Date:
07/03/2019