Provider First Line Business Practice Location Address:
3744 MISSISSIPPI 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:
92104-3316
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
915-355-6638
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/24/2018