Provider First Line Business Practice Location Address:
4204A ADAMS AVE
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:
92116-2300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-431-5049
Provider Business Practice Location Address Fax Number:
866-353-7821
Provider Enumeration Date:
11/29/2018