Provider First Line Business Practice Location Address:
4458 KANSAS ST
Provider Second Line Business Practice Location Address:
APT 6
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-731-9402
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/10/2023