Provider First Line Business Practice Location Address:
5222 BALBOA AVE STE 21
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:
92117-6948
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-249-7660
Provider Business Practice Location Address Fax Number:
858-277-9037
Provider Enumeration Date:
01/20/2026