Provider First Line Business Practice Location Address:
4050 3RD AVE
Provider Second Line Business Practice Location Address:
APT 309
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92103-2139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-349-4035
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/31/2012