Provider First Line Business Practice Location Address:
4320 GENESEE AVE STE 104
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:
92117-4900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-569-5850
Provider Business Practice Location Address Fax Number:
858-569-5855
Provider Enumeration Date:
11/02/2016