Provider First Line Business Practice Location Address:
12321 9TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POWAY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92064-3502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-748-1320
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/19/2026