Provider First Line Business Practice Location Address:
3975 IDAHO ST
Provider Second Line Business Practice Location Address:
#5
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92104-7912
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-739-3906
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/16/2015