Provider First Line Business Practice Location Address:
317 LAUREL 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:
92101-1630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-320-4601
Provider Business Practice Location Address Fax Number:
888-412-0444
Provider Enumeration Date:
03/19/2020