Provider First Line Business Practice Location Address:
2204 NATIONAL 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:
92113-3615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-798-3638
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/25/2016