Provider First Line Business Practice Location Address:
545 LAUREL 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:
92101-1634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-233-4399
Provider Business Practice Location Address Fax Number:
619-233-0453
Provider Enumeration Date:
07/29/2025