Provider First Line Business Practice Location Address:
4646 VAN DYKE 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:
92116-4842
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-649-5787
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/19/2020