Provider First Line Business Practice Location Address:
556 19TH 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:
92102-2804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-436-4191
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/01/2025