Provider First Line Business Practice Location Address:
1775 ELM 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:
92154-1104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-721-9531
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/20/2019