Provider First Line Business Practice Location Address:
3711 GRIM AVE
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:
92104-3650
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-344-3221
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/27/2013