Provider First Line Business Practice Location Address:
5420 55TH ST APT 317
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:
92115-1267
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-662-5154
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/14/2026