Provider First Line Business Practice Location Address:
4145 IOWA ST
Provider Second Line Business Practice Location Address:
APARTMENT 1
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92104-6906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-577-3795
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/16/2008