Provider First Line Business Practice Location Address:
2957 FRIED 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:
92122-2232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-915-6869
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/16/2025