Provider First Line Business Practice Location Address:
1380 S 43RD 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:
92113-3408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-263-8116
Provider Business Practice Location Address Fax Number:
619-263-1989
Provider Enumeration Date:
11/19/2015