Provider First Line Business Practice Location Address:
3655 ASH ST
Provider Second Line Business Practice Location Address:
UNIT 6
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92105-5941
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-669-8196
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/19/2015