Provider First Line Business Practice Location Address:
1855 1ST AVE STE 103
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:
92101-2650
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-627-1887
Provider Business Practice Location Address Fax Number:
619-415-8198
Provider Enumeration Date:
09/14/2022