Provider First Line Business Practice Location Address:
3148 MIDWAY DR # 113
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:
92110-4539
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-619-3630
Provider Business Practice Location Address Fax Number:
619-362-9905
Provider Enumeration Date:
10/21/2015