Provider First Line Business Practice Location Address:
1402 PENNSYLVANIA AVE APT 12
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:
92103-4561
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-988-1218
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/23/2023