Provider First Line Business Practice Location Address:
4879 CORONADO 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:
92107-3315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-391-8688
Provider Business Practice Location Address Fax Number:
512-539-0034
Provider Enumeration Date:
05/09/2016