Provider First Line Business Practice Location Address:
3455 KEARNY VILLA RD
Provider Second Line Business Practice Location Address:
APT 413
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92123-1971
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-455-4009
Provider Business Practice Location Address Fax Number:
916-533-0313
Provider Enumeration Date:
10/10/2016