Provider First Line Business Practice Location Address:
454 W LAUREL 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:
92101-1338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-233-4399
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/21/2025