Provider First Line Business Practice Location Address:
4425 47TH 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:
92115-4516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-208-3688
Provider Business Practice Location Address Fax Number:
858-201-3835
Provider Enumeration Date:
06/20/2023