Provider First Line Business Practice Location Address:
1673 LOGAN AVE UNIT 2
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:
92113-1004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
415-308-7464
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/06/2023