Provider First Line Business Practice Location Address:
4247 54TH PL
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:
92115-6002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-771-8160
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/17/2017