Provider First Line Business Practice Location Address:
4520 ALVARADO CANYON RD APT 452
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:
92120-4343
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-605-3473
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/27/2026