Provider First Line Business Practice Location Address:
4344 CONVOY 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:
92111-3737
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-728-0576
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/20/2022