Provider First Line Business Practice Location Address:
2130 4TH 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:
92101-2110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-298-9383
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/28/2016