Provider First Line Business Practice Location Address:
2461 56TH 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:
92105-5011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-476-6794
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/01/2025