Provider First Line Business Practice Location Address:
2778 C ST APT 8
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:
92102-5102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-807-5949
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/22/2019