Provider First Line Business Practice Location Address:
4145 30TH 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:
92104-1905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-284-3582
Provider Business Practice Location Address Fax Number:
619-284-0619
Provider Enumeration Date:
12/22/2013