Provider First Line Business Practice Location Address:
3853 INGRAHAM ST
Provider Second Line Business Practice Location Address:
APT C219
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92109-6449
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-245-2989
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/09/2015