Provider First Line Business Practice Location Address:
4060 FAIRMOUNT 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:
92105-1608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-280-4213
Provider Business Practice Location Address Fax Number:
619-795-9849
Provider Enumeration Date:
08/19/2016