Provider First Line Business Practice Location Address:
4241 47TH ST APT C
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:
92115-5376
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-483-7171
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/26/2024