Provider First Line Business Practice Location Address:
3919 30TH ST STE 351
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:
92104-3004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-943-4978
Provider Business Practice Location Address Fax Number:
619-873-1681
Provider Enumeration Date:
01/21/2026