Provider First Line Business Practice Location Address:
3990 OLD TOWN AVE STE A208
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:
92110-2967
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-794-4229
Provider Business Practice Location Address Fax Number:
619-330-2003
Provider Enumeration Date:
04/08/2020