Provider First Line Business Practice Location Address:
3817 DEMUS 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:
92115-6511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-961-8421
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/07/2018