Provider First Line Business Practice Location Address:
4514 38TH STREET
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:
92105-1108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-889-0774
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/13/2014