Provider First Line Business Practice Location Address:
4861 CONVOY 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:
92111-1610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-215-4485
Provider Business Practice Location Address Fax Number:
858-565-8504
Provider Enumeration Date:
07/29/2019