Provider First Line Business Practice Location Address:
2613 1/2 WORDEN 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:
92110-5893
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
691-230-5240
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/11/2014