Provider First Line Business Practice Location Address:
1812 29TH 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:
92102-1153
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-389-6352
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/15/2023