Provider First Line Business Practice Location Address:
4438 1/2 UTAH 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:
92116-3122
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-964-7938
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/04/2016