Provider First Line Business Practice Location Address:
2121 IMPERIAL AVENUE
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:
92102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-849-5834
Provider Business Practice Location Address Fax Number:
619-849-5835
Provider Enumeration Date:
10/04/2018