Provider First Line Business Practice Location Address:
2185 CHATSWORTH BLVD APT 9
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:
92107-2456
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-212-1929
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/14/2023