Provider First Line Business Practice Location Address:
4715 30TH ST STE 1
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:
92116-1563
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-793-6808
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/19/2021