Provider First Line Business Practice Location Address:
4203 GENESEE AVE STE 103
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:
92117-4950
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-674-9072
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/31/2017