Provider First Line Business Practice Location Address:
3560 FAIRMOUNT AVE STE B
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:
92105-3420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-877-0124
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/02/2022