Provider First Line Business Practice Location Address:
4254 34TH 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:
92104-1415
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
720-245-5984
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/21/2025