Provider First Line Business Practice Location Address:
330 13TH ST APT PH12
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:
92101-3829
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
917-216-8147
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/16/2025