Provider First Line Business Practice Location Address:
4276 54TH PL STE C
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:
92115-6011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-442-6787
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/27/2019