Provider First Line Business Practice Location Address:
3228 W CANYON AVE
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:
92123-5429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-238-9582
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/08/2026