Provider First Line Business Practice Location Address:
4588 50TH 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:
92115-3305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-530-5141
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/18/2023