Provider First Line Business Practice Location Address:
4453 NORTH AVE APT 3
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:
92116-3942
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-242-5575
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/01/2021