Provider First Line Business Practice Location Address:
402 W BROADWAY STE 74D
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:
92101-3542
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-742-3777
Provider Business Practice Location Address Fax Number:
619-924-7390
Provider Enumeration Date:
04/09/2021