Provider First Line Business Practice Location Address:
4568 KANSAS ST
Provider Second Line Business Practice Location Address:
APT 6
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92116-4257
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-794-5402
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/10/2016