Provider First Line Business Practice Location Address:
8808 BALBOA 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:
92123-1592
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
196-645-0155
Provider Business Practice Location Address Fax Number:
619-645-0193
Provider Enumeration Date:
11/08/2021