Provider First Line Business Practice Location Address:
3136 VANCOUVER AVE
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:
92104-4835
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-990-2611
Provider Business Practice Location Address Fax Number:
619-900-7779
Provider Enumeration Date:
12/20/2016