Provider First Line Business Practice Location Address:
242 OLD OAK DR
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:
92114-6027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-878-1575
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/03/2026