Provider First Line Business Practice Location Address:
6418 AMBROSIA DR APT 5103
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:
92124-3147
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-402-3445
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/20/2026