Provider First Line Business Practice Location Address:
4841 69TH PL
Provider Second Line Business Practice Location Address:
UNIT A
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92115-3016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-329-0588
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/15/2015