Provider First Line Business Practice Location Address:
4074 FAIRMOUNT AVENUE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
691-996-9543
Provider Business Practice Location Address Fax Number:
844-534-8464
Provider Enumeration Date:
03/30/2015