Provider First Line Business Practice Location Address:
4575 COLLEGE 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:
92115-4011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-881-4576
Provider Business Practice Location Address Fax Number:
619-286-0937
Provider Enumeration Date:
12/31/2015