Provider First Line Business Practice Location Address:
4348 54TH 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:
92115-5300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-981-2456
Provider Business Practice Location Address Fax Number:
619-546-7549
Provider Enumeration Date:
07/20/2012