Provider First Line Business Practice Location Address:
4276 54TH PL STE C
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:
92115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-501-5511
Provider Business Practice Location Address Fax Number:
619-501-7770
Provider Enumeration Date:
02/08/2018