Provider First Line Business Practice Location Address:
1419 UNIVERSITY 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:
92103-3459
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-876-4015
Provider Business Practice Location Address Fax Number:
619-883-9360
Provider Enumeration Date:
09/13/2021