Provider First Line Business Practice Location Address:
1965 5TH 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:
92101-2300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-851-6072
Provider Business Practice Location Address Fax Number:
619-241-2992
Provider Enumeration Date:
05/14/2015