Provider First Line Business Practice Location Address:
4527 FANUEL 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:
92109-2904
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-272-2222
Provider Business Practice Location Address Fax Number:
858-272-2414
Provider Enumeration Date:
04/14/2015