Provider First Line Business Practice Location Address:
5052 NORTHAVEN AVE
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:
92110-1116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-869-4815
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/08/2025