Provider First Line Business Practice Location Address:
438 W DATE ST APT 1
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:
92101-2528
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-809-5068
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/08/2020