Provider First Line Business Practice Location Address:
2538 FAIRMOUNT 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:
92105-4717
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-895-3029
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/01/2025