Provider First Line Business Practice Location Address:
6575 LANSTON 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:
92111-6517
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-871-2686
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/24/2020