Provider First Line Business Practice Location Address:
4147 ADAMS AVE
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:
92116-2509
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-850-9889
Provider Business Practice Location Address Fax Number:
619-281-1947
Provider Enumeration Date:
11/17/2017