Provider First Line Business Practice Location Address:
3625 MIDWAY DR
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92110-5253
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-224-2204
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/19/2016