Provider First Line Business Practice Location Address:
3820 CONVOY ST
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:
92111-3722
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-832-7702
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/18/2014