Provider First Line Business Practice Location Address:
1110 24TH ST
Provider Second Line Business Practice Location Address:
APT 8
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-728-4177
Provider Business Practice Location Address Fax Number:
573-503-0122
Provider Enumeration Date:
10/01/2018