Provider First Line Business Practice Location Address:
4161 1/2 HAMILTON 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:
92104-1718
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-931-8734
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/13/2025