Provider First Line Business Practice Location Address:
1424 30TH ST STE A
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:
92154-3417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
195-652-6506
Provider Business Practice Location Address Fax Number:
619-565-2656
Provider Enumeration Date:
06/12/2024