Provider First Line Business Practice Location Address:
1805 LOCUST 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:
92106-1953
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-992-2921
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/15/2021