Provider First Line Business Practice Location Address:
5723 BOUNTY 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:
92120-2916
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-971-8431
Provider Business Practice Location Address Fax Number:
619-639-0336
Provider Enumeration Date:
09/16/2014