Provider First Line Business Practice Location Address:
445 17TH ST
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:
92101-7614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-303-6516
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/23/2024