Provider First Line Business Practice Location Address:
5210 BALBOA AVE STE F
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:
92117-6958
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-239-5433
Provider Business Practice Location Address Fax Number:
619-546-5422
Provider Enumeration Date:
07/15/2019