Provider First Line Business Practice Location Address:
4098 MOUNT ACADIA BLVD
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:
92111-2616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-719-6674
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/28/2025