Provider First Line Business Practice Location Address:
630 1ST AVE STE 145
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:
92101-6976
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-630-9119
Provider Business Practice Location Address Fax Number:
858-327-3544
Provider Enumeration Date:
06/02/2025