Provider First Line Business Practice Location Address:
4230 42ND 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:
92105-1116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-852-9564
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/29/2025