Provider First Line Business Practice Location Address:
2828 W CANYON AVE
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:
92123-4648
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-301-9041
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/27/2019