Provider First Line Business Practice Location Address:
5187 COLLEGE AVE
Provider Second Line Business Practice Location Address:
VILLA ALVARADO E233
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-440-0546
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/17/2021