Provider First Line Business Practice Location Address:
11789 FANTASIA CT
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:
92131-3814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-944-8088
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/11/2026