Provider First Line Business Practice Location Address:
3843 38TH ST APT 1
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:
92105-2459
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-394-5729
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/22/2023