Provider First Line Business Practice Location Address:
3980 9TH AVE # 1
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:
92103-3244
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-618-9638
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/28/2013