Provider First Line Business Practice Location Address:
5511 ADELAIDE AVE
Provider Second Line Business Practice Location Address:
26
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:
619-578-8416
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/27/2017