Provider First Line Business Practice Location Address:
2741 A ST APT H
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:
92102-7023
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-607-5536
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/08/2023