Provider First Line Business Practice Location Address:
5573 BLUERIDGE 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:
92139-3404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-603-7164
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/07/2022