Provider First Line Business Practice Location Address:
1031 25TH 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:
92102-2102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-232-6454
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/07/2022