Provider First Line Business Practice Location Address:
106 THORN 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:
92103-5629
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-450-6532
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/02/2023