Provider First Line Business Practice Location Address:
7456 MISSION GORGE ROAD
Provider Second Line Business Practice Location Address:
UNIT 165
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92120-1301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-535-0773
Provider Business Practice Location Address Fax Number:
619-535-7055
Provider Enumeration Date:
10/15/2025