Provider First Line Business Practice Location Address:
4549 33RD ST
Provider Second Line Business Practice Location Address:
UNIT 4
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92116-4493
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
646-421-5533
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/13/2014