Provider First Line Business Practice Location Address:
2912 INGELOW ST APT 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:
92106-2366
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-347-5190
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/01/2021