Provider First Line Business Practice Location Address:
4029 CHAMOUNE AVE APT 3
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:
92105-1844
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
442-300-8855
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/26/2026