Provider First Line Business Practice Location Address:
4340 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:
92115-5301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-873-4696
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/11/2026