Provider First Line Business Practice Location Address:
3142 MIDWAY DR
Provider Second Line Business Practice Location Address:
APT B-309
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92110-4540
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-260-8352
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/20/2013