Provider First Line Business Practice Location Address:
2830 TUSCALOOSA 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:
92110-4264
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-502-4991
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/13/2016