Provider First Line Business Practice Location Address:
760 BLACKTHORNE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL CAJON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92020-5611
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-851-7189
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/16/2026