Provider First Line Business Practice Location Address:
4423 NEW JERSEY 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:
92116-1050
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-888-6011
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/18/2015