Provider First Line Business Practice Location Address:
5927 BALBOA AVE
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:
92111-2711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-810-6564
Provider Business Practice Location Address Fax Number:
858-225-0410
Provider Enumeration Date:
10/17/2021