Provider First Line Business Practice Location Address:
419 UPAS 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:
92103-4923
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-315-3113
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/19/2016