Provider First Line Business Practice Location Address:
5087 55TH PL
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:
92115-1302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-274-1413
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/08/2023