Provider First Line Business Practice Location Address:
598 W LAUREL ST
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:
92101-1381
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-456-8764
Provider Business Practice Location Address Fax Number:
619-924-7321
Provider Enumeration Date:
04/24/2013