Provider First Line Business Practice Location Address:
4104 DELTA 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:
92113-4113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-802-9993
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/31/2019